<?php echo $this->Html->css('web/org_subscription.css'); ?>

<?php echo $this->element('organisation/web/register_steps', array('active' => 'payments')); ?>

<div class='form-actions well-small'>
    <h4>Billing Information</h4>
    <p>Please review the information provided below and complete your registration</p>
</div>

<form method='post' class='form form-horizontal' action='<?php echo $this->Html->url(array('action' => 'register_payments')); ?>'>

    <div class='control-group'>
        <label class='control-label'>Name On Card:</label>
        <div class='controls'>
            <input type='text' class='input-medium' placeholder='First Name' name='data[Billing][first_name]' required />
            <input type='text' class='input-medium' placeholder='Last Name' name='data[Billing][last_name]' required />
        </div>
    </div>

    <div class='control-group'>
        <label class='control-label'>Card Type:</label>
        <div class='controls'>
            <select class='input-medium' name='data[Billing][card_type]' required>
                <option value=''>Select</option>
                <option value='visa'>Visa</option>
                <option value='mastercard'>Master Card</option>
            </select>
        </div>
    </div>
    
    <div class='control-group'>
        <label class='control-label'>Card Number</label>
        <div class='controls'>
            <input type='text' class='input-large' name='data[Billing][card_number]' required />
        </div>
    </div>
    
    <div class='control-group'>
        <label class='control-label'>Security Code</label>
        <div class='controls'>
            <input type='text' class='input-mini' name='data[Billing][card_security_code]' required />
        </div>
    </div>

    <div class='control-group'>
        <label class='control-label'>Expiry Date:</label>
        <div class='controls'>
            <select name='data[Billing][expiry_month]' class='input-mini' required>
                <option value=''>--</option>
                <option value='01'>01</option>
                <option value='02'>02</option>
                <option value='03'>03</option>
                <option value='04'>04</option>
                <option value='05'>05</option>
                <option value='06'>06</option>
                <option value='07'>07</option>
                <option value='08'>08</option>
                <option value='09'>09</option>
                <option value='10'>10</option>
                <option value='11'>11</option>
                <option value='12'>12</option>
            </select>
            <select name='data[Billing][expiry_year]' class='input-small' required>
                <option value=''>--</option>
                <?php for ($y = date('Y'); $y < intval(date('Y')) + 10; $y++) { ?>
                    <option value='<?php echo $y; ?>'><?php echo $y; ?></option>
                <?php } ?>
            </select>
        </div>
    </div>
    
     <div class='form-actions'>
        <a type='button' class='btn' href='<?php echo $this->Html->url(array('action' => 'register_info')); ?>'><i class='icon icon-backward'></i> Back</a>
        <button type="submit" class="btn btn-success"><i class='icon icon-forward'></i> Continue</button>
        <a class="btn btn-cancel" href='<?php echo $this->Html->url(array('action' => 'register_cancel')); ?>' >Cancel</a>
    </div>
</form>